How did you hear about us? (Friend,Relative,Phone Book) Patient Information: Patient s Name: Male / Female: Last First Middle Preference.

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1 HERNDON DENTAL CENTER Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us we will be happy to help. How did you hear about us? (Friend,Relative,Phone Book) Patient Information: Patient s Name: Male / Female: Last First Middle Preference Address: Street Apt. # City State Zip Date of Birth: Social Security #: (Please provide all telephone numbers to contact you. There may be times when we need to reach you on short notice.) Home: Work: ext Cell: Emergency Contact Information: Name: Phone: Address: City: State: Zip: Subscriber Responsible Party Information: Name: Male / Female DOB: Last First Middle Social Security #: Relation to patient: Mailing Address: City: State: Zip: Home phone: Work phone: ext Employer: Occupation: Address: No. Years Employed: Primary Dental Insurance (Leave blank only if no dental benefits) Ins. Company Name: Address: City: State: Zip: Phone: Group No.: Id Number: Secondary Dental Insurance (Leave blank only if no dental benefits) Ins. Company Name: Address: City: State: Zip: Phone: Group No.: Id Number: Additional Information Preferred Pharmacy& Phone: School Name: School Location: Student Status: Full-time or Part-time Broken Appointment Policy: Reserved appointment time in any dental office is limited and valuable. It is extremely important that all patients honor their reserved dental appointments. Failure to do so deprives our other patients from receiving needed dental care in a timely fashion. So that the dentist, our staff, and our other patients will not be penalized by those who fail to keep scheduled appointments, our office policy stipulates that failure to give sufficient warning to keep a scheduled appointment, (48 hours advance notification), will result in a $50.00 fee being charged per ½ hour. That charge

2 which is in accordance with our dental office s broken appointment policy for all of our patients is to be paid prior to the scheduling of any new appointment. The patient is responsible for payment of the charge. Please feel free to discuss this and other policies with our office staff. Patient s Signature: Date: Parent/Guardian signature if patient is a minor: Dental History: 1. Reason for this visit 2. Name of previous dentist 3. Date of last complete series of dental x-rays Date last treated 4. Are you having pain at this time? YES NO If yes, where, and for how long?: 5. Do you require antibiotics prior to dental treatment? YES NO 6. Have you ever had any of the following? a. Orthodontic treatment? Braces - Year YES NO b. Oral surgery? Extractions - Year YES NO c. Periodontal treatment? Gum Treatment - Year YES NO 6. Do you feel very nervous about having dental treatment? YES NO Medical History: 1. Are you in good health? YES NO 2. Has there been a change in your general health within the past year?. YES NO 3. Are you under the care of a physician during the past two years? YES NO a. Name of Physician City Phone b. Date of last medical exam Do you have a current medical problem? YES NO If yes, please state 5. Have you been a patient in the hospital for any operation or illness within the past 5 years? YES NO 6. Are you allergic to (i.e., itching, rash, and swelling) or made sick by any of the following medications? YES NO If so please circle all that apliy: Aspirin Erythromycin lidocaine or Marcaine Scopolamine Codeine Local Anesthetic Penicillin Sleeping Pills Darvon Nembutal/Seconal Percodan Tetracycline Demoral Nitrous Oxide Other Antibiotics Vicodin Valium 7. Have you taken any medicine or drugs, including weight reduction medication and herbal supplement, during the past two years? YES NO Please list: 8. Do you have or have you had any of the following diseases or problems? Please circle: AIDS/HIV Positive Anemia Arthritis Artificial Joint Artificial Heart Valve Asthma Chemotherapy (Cancer, Leukemia) Congenital Heart- Defects/Lesions Diabetes Emphysema Epilepsy/Seizures Heart Attack/Disease Heart Failure Heart Murmur Heart Pacemaker Hepatitis A (Infectious) Hepatitis B (Serum) High Blood Pressure Low Blood Pressure Kidney Trouble Liver Disease Mitral Valve Prolapse Nervousness Pain in Jaw Joints Psychiatric Treatment Rheumatic Fever Scarlet Fever Sickle Cell Disease/Traits Sinus Trouble Stroke STD or VD (Syphilis, Gonorrhea) Thyroid Disease Tuberculosis (TB) 9. Do you have a disease, condition, or problem not listed above that you think I should know? YES NO If yes, please explain: 10. FOR WOMEN ONLY: ARE YOU PREGNANT? YES NO If YES, what month? Are you taking birth control pills? YES NO Authorization: 1. If I ever have any change in my health, or if my medicines change, I will inform the doctor at the next appointment without fail. 2. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. All procedures have risks, these include, but not limited to: Drug reactions/side effects, damage to adjacent teeth or fillings, post operative sensitivity to temperature and/or pressure, bruising/pain/swelling, failure of dental procedure, necessitating additional treatment, complications during treating necessitating referral to a specialist. 3. I authorize and consent to any x-rays, examination, anesthetics, sedative, or dental treatment rendered for myself and/or children under the general, direct, or indirect supervision of Dr. Farhad Hakim D.D.S. 5. I understand that diagnostic radiographs are necessary to ensure optimum dental health. I will not hold Dr.Farhad Hakim D.D.S. liable for any failure to diagnose or any misdiagnosis due to my refusal for recommended x-rays. I will take full responsibility for any conditions relating to my dental health that may not have been diagnosed or misdiagnosed due to lack of radiographs. 7. I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluation and administering insurance benefits.

3 Herndon Dental Center Farhad Hakim, D.D.S. 625 Elden St., Suite 201 Herndon, VA I hereby authorize payment of insurance benefits directly to the dentist, otherwise payable to me. 9. I attest to the accuracy of the information on this page. PATIENT DATE PARENT OR RESPONSIBLE PARTY RELATIONSHIP TO PATIENT Financial Policy Thank you for choosing us as your dental care provider. Our office is committed to providing you with the best possible care. Please understand that payment of your bill is considered as part of your treatment. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment. All patients must complete our Information and Insurance form before seeing the doctor. Regarding Payment We accept the following forms of payment: Cash, Check, Visa, American Express, Discover and MasterCard. Payment for services is due at the time services are rendered unless prior arrangements have been made with the doctor and the billing receptionist. If dentures, partial dentures, crown and bridge are to be fabricated by a dental laboratory, a 50% deposit will be required at the time of the first impression. The remaining balance is due at the time the prosthesis is cemented or inserted. The parent that accompanies the minor child/children to the appointment is responsible for any payment due. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized before the appointment date or previous arrangements have been made with the doctor and billing receptionist. Regarding Insurance Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. In the event we do accept assignment of benefits and your insurance company has not paid your account in full within 60 days, the balance may be transferred to your account. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and customary under the terms of your insurance policy. Our practice is committed to providing the best treatment for our patients and we charge what is the usual and customary for our area. You are responsible for payment regardless of any insurance companies arbitrary determination of usual and customary rates. Your complete insurance information must be presented at the time services are provided. Most benefits will be verified before your insurance company can be billed. All insurance co-pays and deductibles must be paid at the time of service. We would be happy to discuss our charges and how they relate to your particular situation. We

4 also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. Missed Appointments Once an appointment has been made, please remember that this time has been reserved specifically for you. We reserve the right to charge a fee of $25 per ½ hour for all cancelled or missed appointments without 48 hours notice. Specialty Services A 25% deposit is due at time of appointment scheduling for all surgical and sedation procedures. Service Charges The policy of this office is to charge 1% monthly interest (12% annual percentage rate) or a billing charge that will be applied to all accounts over 90 days past due. We will charge $40 for returned checks. Collection Fees Fees incurred to collect payment will be billed to and payable by the patient s account holder. Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. I have read the Financial Policy. I understand and agree to this Financial Policy. Signature of Patient or Responsible Party: Date:

5 Statement of Privacy Practices We at Herndon Dental Center are dedicated to protecting the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensuring that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices, but will always inform you of any changes that might affect your rights. Protecting Your Personal Health Care Information We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Virginia. This includes issues relating to your treatment, payment, and our dental care operations. Your personal health information will never be otherwise given to anyone even family members without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose. Our offices and electronic systems are secure from unauthorized access, and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released. Collecting Protected Health Information We will only request personal information needed to provide our standard of quality dental care, implement payment activities, conduct normal dental practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law. Disclosure of Your Protected Health Information As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and government officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointment including voic messages, answering machines, and postcards. Patient Rights You have a right to request copies of your health care information; to request copies in a variety of formats; and to request a list of the instances in which we, or our business associates, have disclosed your protected information for uses other that those stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

6 We thank you for being a patient of Herndon Dental Center. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information. Acknowledgement of Receipt of Statement of Privacy Practices I acknowledge that I have received a copy of the Statement of Privacy Practices for the Herndon Dental Center. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health care information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in this facility. Herndon Dental Center reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me. Additional Disclosure Authority In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below. ANY MEMBER OF MY IMMEDIATE FAMILY YES NO SPOUSE ONLY YES NO OTHER (please specify) YES NO Name of Patient or Personal Representative Date Signature of Patient or Personal Representative Description of Personal Representative s Authority Office Use Only Below This Line Record of Acknowledgement Not Obtained Provided prior to treatment? YES NO Date Provided Reason for Denial: Needed more time to review Statement of Privacy Practices Wanted to consult with another person before signing Reason not given

7 Other (explain)